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Hospital Benefit Specialist-KZN
The successful applicant will be responsible for but not limited to the following job functions:
Assessing the case in relation to the following:
- Members clinical history
- Members benefit structure
- Clinical Information and coding supplied
- Level of care provided
- Appropriateness of the facility
- Appropriateness of the treating doctor
- Appropriateness of treatment
- Managing the benefit for the member and the risk for the relevant scheme through a thorough process to approve or decline Funding to ensure that the member gets the appropriate level of care
- Discharge planning by providing the member with alternatives to receive treatment ( This includes Hospital @ Home, Homecare etc.)
- Effective and accurate communication to all stakeholders:
- Case update to the provider
- Funding decisions and benefit confirmation to the members
- Request for additional information from the treating doctor or practice manager
- Engaging with Patient Services Manager and hospital staff
- Handling escalations from Providers and internal stakeholders
- Preparing and presenting complex case to clinical review
- Trend Analysis of inefficiencies and proposals to correct
- Appropriate internal case referrals for clinical management
- Attend to patients on daily report
- Review all low acuity admission requests
- Quality of processes
- Onsite perception survey
- Emotional Intelligence – Ability to understand, use, and manage emotions in positive ways to communicate effectively, empathise with others and defuse conflict.
- Composure – Is cool under pressure; does not become defensive or irritated when times are tough; is considered mature; can be counted on to hold things together during tough times; can handle stress; is not knocked off balance by the unexpected; doesn’t show frustration when resisted or blocked; is a settling influence in a crisis.
- Conflict Management – Steps up to conflicts, seeing them as opportunities; reads situations quickly; good at focused listening; can hammer out tough agreements and settle disputes equitably; can find common ground and get cooperation with minimum noise.
- Decision Quality – Makes good decisions (without considering how much time it takes) based upon a mixture of analysis, wisdom, experience, and judgment; most of his/her solutions and suggestions turn out to be correct and accurate when judged over time; sought out by others for advice and solutions.
- Integrity and Trust – Is widely trusted; is seen as a direct, truthful individual; can present the unvarnished truth in an appropriate and helpful manner; keeps confidences; admits mistakes; doesn’t misrepresent him/herself for personal gain.
- Negotiating – Can negotiate skillfully in tough situations with both internal and external groups; can settle differences with minimum noise; can win concessions without damaging relationships; can be both direct and forceful as well as diplomatic; gains trust quickly of other parties to the negotiations; has a good sense of timing.
- Perseverance – Pursues everything with energy, drive, and a need to finish; seldom gives up before finishing, especially in the face of resistance or setbacks.
- Problem Solving – Uses rigorous logic and methods to solve difficult problems with effective solutions; probes all fruitful sources for answers; can see hidden problems; is excellent at honest analysis; looks beyond the obvious and doesn’t stop at the first answers.
Education and Experience:
The following requirements are essential:
- Must be a Registered Nurse
- Valid SANC Registration
- 3 years Clinical experience in a private hospital setting (ICU, Trauma/Casualty, Medical/General ward preferable)
- 2 years Managed health care experience
- Microsoft Office (Specifically Excel experience)
- Valid Driver’s License and own transport ( working hours are between 08:30 -17:00 & travel up to 50KM may be required)
- Effective Communication Skills (Verbal & Written)
- Telephone Etiquette
- Active Listening Skills
The following requirements will be advantageous
- 1 – 2 years ICU experience
- Knowledge of DH SOP’s and Process experience (internal only)
- Provider payment arrangements (internal Only)
- Clinical coding knowledge of ICD-10 and/or CCSA
Method of Application
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